The "not so good" thyroid cancer: a scoping review on risk factors associated with anxiety, depression and quality of life

The incidence of thyroid cancer has increased in recent years, leading to a growing number of survivors facing lifelong consequences. This scoping review investigated anxiety, depression, and quality of life (QoL) in thyroid cancer survivors compared to the general population, those with benign pathology, and survivors of other types of cancers. Moreover, we aimed to identify the risk factors associated with anxiety, depression, and QoL in thyroid cancer patients. A total of 727 articles were identified through PubMed, ProQuest, Cochrane, and Google Scholar databases, and 68 articles that met the criteria were selected for data extraction. Thyroid cancer survivors have a poorer QoL compared to the general population, population with benign pathology, and survivors of other types of cancer associated with worse clinical outcomes. The main risk factors are grouped into socioeconomic factors, disease-specific factors, management factors, comorbidities, and patient perceptions. Effective communication between the patient and the medical team and behavioral interventions may reduce these risks. Despite the common perception of thyroid cancer as a "good cancer," the findings of this review demonstrate the need to address the risk factors associated with increased anxiety, depression, and lower QoL in survivors.


INTRODUCTION
Thyroid cancer (TC) develops from uncontrolled cell division in the tissues of the thyroid gland [1]. It is the most common type of endocrine cancer worldwide and ranks 9th in terms of overall cancer incidence [2]. In the UK, the incidence of TC is projected to increase from 6.5 to 11 cases per 100,000 individuals between 2014 to 2035 [3]. This type of cancer is more commonly diagnosed in women than men, with a prevalence that is approximately 2 to 3 times higher among women and is also one of the leading cancers among adolescents and young adults (AYAs) [4]. Despite its increasing incidence, TC has a very good prognosis, with a reported 5-year survival rate of 87% [5].
TC is usually asymptomatic in the early stages, but symptoms such as neck pain, hoarseness, and dysphagia may occur as the disease progresses. TC is diagnosed by physical examination, analysis of thyroid hormone levels, imaging, and biopsy [5]. The management of TC depends on the type and stage of cancer and patient preference. For low-risk TC, annual surveillance is recommended instead of immediate treatment [6]. The most frequent intervention is surgery, which includes either the complete removal of the thyroid (thyroidectomy), a partial thyroid removal (thyroid lobectomy), and/or lymph node dissection [7].
Radioactive iodine (RAI) is another treatment option, although it may cause side effects such as reduced fertility, salivary gland dysfunction, leukopenia, and eye inflammation [8]. Although less frequently used, other alternatives to surgery include external radiotherapy, chemotherapy, and targeted drug therapy [7]. In addition, patients often require lifelong levothyroxine for thyroid hormone supplementation and suppression of TSH-stimulated cancer growth [5].
Patients with cancer often experience significant psychological issues, including mood and anxiety disorders [9]. As a result, quality of life (QoL), which includes psychological, social, and spiritual well-being, has become an important consideration in the management of cancer survivors [10].
Due to the increasing incidence and improved prognosis of TC, a growing number of survivors are living with the effects associated with diagnosis and ongoing surveillance [11]. In addition, patients may experience depression as a comorbidity, with one study suggesting TC survivors have one of the highest depression prevalence among other cancer types [12].
This review aimed to compare the levels of anxiety, depression, and QoL in TC survivors with those of the general population, individuals with benign pathology, and survivors of other cancer types. Moreover, we aimed to investigate the risk JOURNAL of MEDICINE and LIFE factors associated with anxiety, depression, and low QoL in TC survivors.

MATERIAL AND METHODS
In this scoping review, we adopted Arksey and O'Malley's [13] scoping review framework, which includes the (1) identification of the research questions, (2) identification of relevant studies, (3) study selection, (4) charting the data, (5) collating, summarizing, and reporting the results.
Step 1: Identifying the research questions Step 2: Searching for relevant studies For this scoping review, we conducted an electronic search for articles written in English and published between 2015 and 2021, using Cochrane Library, ProQuest, PubMed, and Google Scholar databases. The search was conducted from June 2020 to December 2021. Our aim was to find primary studies that investigated and analyzed the links between thyroid cancer and QoL/ depression/anxiety. The search was performed in the selected databases using the keywords "thyroid cancer AND (anxiety OR depression OR quality of life)". To ensure a comprehensive search and avoid duplication of results, a Boolean search was applied within each database. This method enabled us to get a large search output for eligible studies without using a multiple-stage search strategy.
Furthermore, studies reported that TC patients had higher levels of anxiety and depression compared to the general population [27,28]. Two studies investigated the association between depression, anxiety, or QoL in TC patients versus those with benign pathologies [23,30]. Giusti et al. [23] found that TC patients had no major differences in QoL but reported a significantly higher level of hyperthyroidism-related symptoms when compared to patients with benign thyroid pathology. Chow et al. found that TC patients experiencing complications from surgery and RAI had significantly worse QoL scores than those who did not [29]. In addition, a study by Teliti et al. [30] established that differentiated thyroid cancer (DTC) patients had worse QoL than patients with benign thyroid pathology. Overall, these studies suggest that TC survivors experience compromised QoL compared to the general population or those with benign pathology.

TC patients vs. patients suffering from other types of cancer
Three studies examined the QoL, anxiety, and depression of TC patients compared to patients suffering from other types of cancers (Table 2) [31][32][33]. According to Applewhite et al. [31], TC survivors had a comparable QoL to the colon, glioma, and gynecological cancer survivors but a worse QoL than breast cancer survivors. Additionally, TC survivors reported inadequate support and having their diagnosis trivialized by healthcare professionals, as their cancer was commonly labeled as a "good cancer". Interestingly, one study [32] reported that TC survivors experienced higher levels of anxiety and depression compared to survivors of breast, colorectal, uterine, and prostate cancers or non-Hodgkin's lymphoma. The authors suggested that the continued surveillance of TC patients during the survivorship period contributes to anxiety and fear of cancer recurrence [32]. Aschebrook-Kilfoy et al. [33] found that TC patients had a lower QoL than patients with more invasive cancers, which is associated with worse disease outcomes. The study also highlighted that the psychological issues experienced during TC survivorship might be overlooked due to its good prognosis and suggested that the actual prognosis of cancer may have little correlation with its psychological impact [33]. Overall, the studies indicate that despite having a highly treatable "good" cancer, TC patients are not less likely to have a poor QoL and may even experience more prolonged periods of emotional distress compared to survivors of other cancers with worse prognoses.

Risk factors associated with anxiety, depression, and low QoL in TC patients
The current review has identified several risk factors associated with anxiety, depression, and low QoL in TC patients, which were grouped into the following categories: socioeconomic factors, disease-specific factors, management factors, comorbidities, and patient perceptions.
Age Age has been associated with decreased QoL in older adults and increased worry in younger adults, although some studies have reported conflicting results. For example, older age has been associated with a decreased QoL in some studies [19,25,34,35], while younger age has been associated with increased worry [34,35]. However, other studies have reported that younger age is associated with a lower QoL in TC patients [14,33,37,38].

Mols et al. [25]
Cross-sectional study on QoL of TC survivors (n=293) using the EORTC QLQ-C30 and THYCA-QoL questionnaires. Results were compared against national normative data.
The Netherlands Adolescent and young adult TC survivors scored worse than agematched controls in physical, role, cognitive, and social functioning aspects of QoL. They also experienced more fatigue and financial problems. Among TC survivors, adolescent and young adults scored better in physical function and interest in sex than the elderly and reported less autonomic and throat or mouth problems than those who are middle-aged.

Socioeconomic factors
Age: Younger patients associated with increased QoL in various aspects compared to middle-aged and elderly patients Retrospective matched-pair study on the effect of remnant radioiodine ablation on QoL in low-risk DTC patients (n=122 pairs) using the PROMIS-29
USA QoL of DTC patients was worse than the US general population.
QoL was not significantly different between surgery only and surgery plus RAI. Those with treatmentrelated complications reported significantly worse QoL than those without. RAI-associated xerostomia was also correlated with a worse QoL.

Treatment-related factors
• Complications: associated with lower QoL

Teliti et al. [30]
Comparative cross-sectional study evaluating sleep quality and its effects on QoL in DTC patients (n=119) compared to controls with benign thyroid pathology. QoL was measured using the Thyroid-specific patient-reported outcome (ThyPRO), the Billewicz scale (BS), and the ad-hoc visual analogic scale (VAS).
Italy DTC patients had worse QoL overall compared to the control group with benign thyroid pathology. In DTC patients, the levels of insomnia were significantly correlated with increased age and lower QoL.

Comorbidities
• Insomnia: associated with a worse QoL

Socioeconomic factors
• Age: younger patients at higher risk of decreased QoL; • Sex: females at higher risk of decreased QoL; • Educational level: patients with low educational level at higher risk of decreased QoL.  AYAs and older patients who believed their illness would continue for a long time reported more distress.

Socioeconomic factors
• Age: Younger individuals had more faith in their treatment, confidence about the control of their treatment, and greater understanding of their illness.

Patients' perceptions
• Patients who believed that their illness would persist for a prolonged duration experienced more distress.

Moon et al. [37]
Prospective cohort study on QoL of patients with low-risk papillary thyroid microcarcinoma undergoing active surveillance (n= 674) or immediate surgery (n= 381).

South Korea Patients who underwent active surveillance had better
QoL overall than those who had immediate surgery. Among those who chose immediate surgery, those who had lobectomy/ isthmusectomy had a better QoL than those who had total thyroidectomy. A higher QoL score was associated with older and male patients.

Socioeconomic factors
• Age and Sex: Older age and male sex associated with higher QoL Management factors • Active surveillance: associated with higher QoL compared to surgery; • Lobectomy: associated with better QoL than thyroidectomy. Table 3. Studies examining risk factors associated with lower QoL in thyroid cancer patients. Cross-sectional study, quantifying cancer-related worry in TC patients (n=941), using the ASC questionnaire.
Canada Younger TC survivors and those with confirmed or recurrent/persistent disease activity experienced the highest levels of cancer-related worry. Time since thyroid cancer diagnosis (≤ 5 years) and partnered marital status were also associated with increased worry. RAI was not significantly associated with worry.

Socioeconomic factors
• Age: younger patients at higher risk of cancer-related worry; • Family status: partnered marital status at higher risk of cancer-related worry.

Disease-specific factors
• Current suspected or proven recurrent/persistent disease: associated with increased worry

Socioeconomic factors
• Age: patients <55 years' experience increased sensitivity; • Sex: female patients experience more nausea and vomiting.

Management factors
• RAI: may affect HRQoL negatively, yet patients may experience an improvement in global HRQoL post-therapy. USA Lower educated patients were more likely to overestimate the risk of recurrence and mortality compared to those with college experience. Hispanics also overestimated the risk of recurrence. Those who over-estimated also had greater worry about recurrence and death, which was also associated with a decreased QoL.

Socioeconomic factors
• Education: lower education associated with overestimation of the risk of recurrence and mortality; • China Significant risk factors for preoperative anxiety and depression include higher educational level (high school and above), paying for the treatment at their own expense, and poor quality of sleep.

Socioeconomic factors
• Education level: higher educational level (high school and above) associated with increased preoperative anxiety and depression; • Payment for one's own treatment: associated with increased preoperative anxiety and depression.

Mongelli et al. [48]
Cross-sectional study of the financial burden and QoL in TC patients (n=1743).
USA Financial problems and living in poverty were associated with worse anxiety/depression in TC patients.
Lost productivity at work was associated with worse fatigue & social functioning.
The inability to change jobs was associated with worse fatigue, pain, and decreased social functioning. Those receiving disability benefits reported worse pain interference.

Socioeconomic factors
• Financial status: financial problems and living in poverty associated with increased anxiety and depression; • Loss of productivity at work: associated with worse fatigue and social functioning.

Chan et al. [49]
Cross-sectional study of risk factors associated with QoL in DTC patients (n=613) using the EORTC QLQ-C30 and THYCA-QoL questionnaires.
Hong Kong Fatigue and insomnia are the two common symptoms experienced by DTC patients. Poorer QoL was associated with the following: serum thyrotropin (TSH) of more than 1.0 mIU/L, unemployment, and concomitant psychiatric disorders.

Comorbidities
• Psychiatric illness: associated with lower QoL

Socioeconomic factors
• Unemployment: associated with lower QoL

Treatment-related factors
• High TSH levels: associated with lower QoL

USA
Higher levels of financial distress and being diagnosed for <5 years were related to worse QoL in all 7 domains.
In TC survivors, employment status was an independent risk factor for QoL, with those unable to get a new job or change jobs also reporting worse fatigue, pain, and social functioning.

Socioeconomic factors
• Italy There were no statistically significant differences in the QoL of patients before, during, or at the end of the 6 months. During the 6 months, there was a small improvement in the general health, emotional and cognitive status but a worsening of the physical role and social functioning.
Lenvatinib was also associated with side effects of fatigue, anorexia/weight loss, and stomatitis.

Banihashem et al. [55]
Prospective study assessing QoL in females (n=121) and males (n=29) with DTC before, during, and after treatment with RAI. HADS and SF-36 questionnaires were used.
Iran QoL became increasingly better in patients over several months after treatment with RAI, although there was no significant difference before and during RAI treatment.
The role of age, gender, RAI dose, and thyroid-stimulating hormone level at the time of RAI, showed no statistical significance.

Management factors
• RAI: associated with improved QoL afterward. Results from the THYCA-QOL showed that thyroidectomy was associated with a worse scar appearance and hence QoL than lobectomy. There was no significant difference in the FoP-Q-SF results between the groups.

Treatment-related factors
• Thyroidectomy: associated with a lower QoL compared to lobectomy.

Bongers et al. [63]
Cross-sectional study comparing South Korea QoL in relation to neck appearance was higher following transoral robotic thyroidectomy than after transcervical thyroidectomy. Total QoL scores however did not differ in the 2 groups after surgery.

Treatment-related factors
• Transcervical thyroidectomy: associated with worse perception of neck appearance than transoral robotic thyroidectomy.

Chen and Chen [67]
A retrospective cohort study comparing postoperative QoL and cosmetic outcome between minimally invasive video-assisted thyroidectomy (MIVAT) and bilateral axillo-breast approach (BABA) robotic thyroidectomy.
Taiwan No significant difference in scar perception between the two groups. However, the MIVAT group had better postoperative aspects of QoL than the BABA robotic group such as general health, vitality, mental health, and health change.

Treatment-related factors
• Bilateral axillo-breast approach robotic thyroidectomy: associated with lower QoL compared to minimally invasive video-assisted thyroidectomy. China No statistically significant difference in the scores of FoP-Q-SF, between the two groups.

Metallo et al. [69]
Cross-sectional study on QoL and self-esteem and pregnancy outcomes of female DTC survivors (n=45) treated with thyroidectomy and I131 before the age of 25. The SF-36 and ISP-25 questionnaires were used.
France Young and female DTC survivors reported no long-term negative impacts of TC on their QoL, self-esteem, or pregnancy outcomes.

Wiener et al. [70]
Cross-sectional study of the relationship between type D personality and QoL in DTC survivors (n=284).
USA Depression itself, and not Type D personality, was an independent predictor of QoL in DTC survivors and negatively impacted QoL in all domains.

Comorbidities
• Pre-existing depression: has a negative impact on QoL

Henry et al. [71]
Cross-sectional study on the experiences, preferences, and needs of TC (n=17) patients using interviews.
Canada Uncertainty and lack of support/being overlooked due to TC's good prognosis are recurring themes among TC patients.

Patients' perceptions
• Fear about surgical complications, metastasis • Lack of support

Randle et al. [72]
Prospective qualitative study on QoL of papillary TC patients (n=31) before and after thyroidectomy using semistructured interviews.
USA The notion that TC is a "good cancer" is widely spread throughout the healthcare system, online search results, and social circles. This had a negative impact on the patients as it invalidates their experiences and fears, and was found to be a cause of mixed/confusing emotions.

Patients' perceptions:
• Feeling their experiences are invalidated due to TC being overly considered as a "good cancer".

Romania
Psychological well-being in DTC patients was related to treatment, diagnostic tests, and the possibility of recurrence/metastasis. No relations were found between age/gender and QoL.

Disease-specific factors
• Possibility of recurrence: related to worse psychological well-being and therefore decreased QoL

Management factors
• Treatment: related to worse psychological well-being and therefore decreased QoL; • Diagnostic tests: related to worse psychological wellbeing and therefore decreased QoL.

Hedman et al. [74]
Prospective population-based study, studying changes in HRQoL from diagnosis to one-year follow-up, in DTC patients (n=235). SF-36 and a studyspecific questionnaire were used at the two-time points.
Sweden HRQoL in patients was most affected at the time of diagnosis, with improvements in some patients after one year.
Having a fear of recurrence and a negative view of life, were the two most influential factors affecting HRQoL negatively after one year.

Patients' perceptions
• Fear of recurrence: associated with lower HRQoL; • Negative view of life: associated with lower HRQoL. Sweden Anxiety in TC patients was mainly due to fear of recurrence and exhausting effective treatment options.

Patients' perceptions
• Fear of recurrence: related to increased anxiety; • Fear of lack of effective treatment options in the future: related to increased anxiety.
The Netherlands QoL was poorer in DTC survivors who had the following perceptions about their illness: it had many negative consequences, it was the cause of their symptoms and negative emotions, and it could be controlled by treatment.

Patients' perceptions
• Negative perceptions from patients: correlates with a decreased QoL.

Liu et al. [78]
Prospective study on the impact of scar appearance post thyroidectomy on QoL and satisfaction with aesthetic effect using the EORTC QLQ-C30 and Patient Scar Assessment Scale (PSAS).
China QoL was inversely related to PSAS score (where higher equals a worse appearance due to scar irregularity and length)

Patients' perceptions
• Poor satisfaction of post-surgical cosmesis: associated with lower QoL.

JOURNAL of MEDICINE and LIFE
One study [28] found that young female adults (≤44) suffering from TC had an increased incidence of depression compared to older females, whereas another study [39] showed that younger patients were at a higher risk of cancer-related worry compared to older patients. Despite the good prognosis of TC, young patients may feel dismissed and experience uncertainty about their future [40]. Older age was linked to better pain management and improved perception of appearance, which is associated with higher QoL [41][42][43].

Family status
Family status has been investigated in relation to depression, anxiety, and QoL in TC patients across several studies [15,34,39,44,45]. While being in a "partnered marital status" and "having children" were associated with increased cancer-related worry, being married was linked to decreased QoL in some studies [39,44]. However, being married was found to be associated with a favorable QoL compared to being unmarried or divorced in other studies [15,45].

Education and ethnic background
Higher educational level was associated with a higher QoL in TC survivors [15,33,34,44,46], although two studies [24,47] reported conflicting results and a higher level of education was associated with a significantly lower QoL and increased pre-surgery anxiety and depression respectively. In terms of ethnic background, one study reported that Asian and Hispanic TC patients in the USA experienced greater worry compared to Caucasian patients [35].
Financial and employment status Financial strain and employment status have also been associated with anxiety, depression, or QoL in TC [15,24,26,28,35,44,[47][48][49][50]. Financial difficulties were reported in 43% of TC survivors, leading to higher levels of anxiety and depression, lost productivity, and an inability to change jobs [48]. Low-income TC patients experienced higher rates and longer periods of depression one year after thyroidectomy compared to higher-income patients [28]. Similarly, lower socio-economic backgrounds were linked to increased cancer-related worry and worse QoL scores [15,35,50]. Hossain et al. [44] found that higher family income was associated with decreased QoL. Unemployment significantly lowered the QoL of TC survivors in three studies [24,26,49], while paying for treatment out-of-pocket was associated with increased preoperative anxiety and depression in one study [47].

Disease-specific factors
Several studies have identified disease-specific factors associated with anxiety, depression, and low QoL in TC patients [22,23,26,28,39,44,45,50,51]. These factors include tumor TNM stage and the presence of metastases, physical symptoms, current active disease or cancer recurrence, and time since diagnosis and treatment. For example, a higher tumor TNM stage and the presence of metastases have been associated with a lower QoL in some studies [22,25,45]. Physical symptoms have also been found to be a significant predictor of lower QoL in TC patients [44,51]. Moreover, TC patients with current active disease or cancer recurrence experienced more cancer-related worry compared to those in remission [39]. Another disease-related risk factor for TC patients is the time since diagnosis and treatment. Several studies [23,43,50] reported that a longer time since diagnosis was associated with a better QoL. In addition, TC patients in the later stages of survivorship (>5 years) had less cancer-related worry than those in the earlier stages [39]. Consistently, Choi et al. [28] reported that TC survivors had a signifi-cantly higher incidence of depression in the first postoperative year compared to matched controls.
Hypothyroidism, Levothyroxine withdrawal, and Lenvatinib The development of hypothyroidism and hypoparathyroidism after treatment of TC has been associated with a significantly worse QoL score [14,52]. Withdrawal of levothyroxine, a medication used to treat hypothyroidism, is also a risk factor for decreased QoL [19,53]. Conversely, exogenous TSH stimulation was associated with improving certain aspects of QoL [21], while higher TSH levels were associated with a lower QoL [49].
Radioactive iodine treatment Radioactive iodine treatment (RAI) has been extensively studied as a predictive and protective factor of QoL among TC patients. While some studies have reported improvements in QoL and emotional and cognitive function after RAI treatment, patients have also reported significant side effects such as nausea, vomiting, and RAI-induced xerostomia [29,42] that negatively impact QoL. Banihashem et al. [55] discovered that QoL only improved several months after RAI treatment, whereas some studies provided evidence that RAI had a negative impact on QoL [14,22,38,56,57]. One study found that TC patients receiving RAI treatment did not have significantly different levels of worry compared to those not receiving RAI [39]. Patients undergoing RAI reported feeling isolated and dirty due to the compulsory glove-wearing and showering three times a day and perceived themselves as different from other cancer patients [40].
Active surveillance, lobectomy, and thyroidectomy Active surveillance as an alternative to surgery is associated with a higher QoL [37,58] and lower levels of anxiety and depression compared to thyroidectomy [59]. Complications arising from thyroidectomies, such as neurological deficits resulting from nerve damage [45] and impaired communication, a primary complaint among TC patients and a significant source of frustration [60], may explain the negative impact of surgery on QoL outcomes.
Research suggests that QoL differs among TC patients who undergo lobectomy, hemithyroidectomy, or total thyroidectomy. Four studies [37,45,61,62] reported that lobectomy was associated with a better QoL than thyroidectomy. In contrast, one study [63] reported that hemithyroidectomy was associated with a higher worry of recurrence compared to thyroidectomy, whereas Luddy et al. [64] reported no significant differences in the mental and physical domains of QoL in patients who underwent thyroidectomy compared to patients that underwent lobectomy.
Other surgical approaches Two studies found no significant differences in QoL between patients who underwent transoral robotic thyroidectomy and those who underwent conventional open thyroidectomy [65,66]. A retrospective study [67] found that patients receiving minimally invasive video-assisted thyroidectomy had better QoL outcomes compared to the bilateral axillo-breast approach robotic thyroidectomy. Furthermore, Lan et al. [68] reported no significant differences in QoL scores between patients who received radiofrequency ablation (RFA) and those who underwent surgery. Finally, Metallo et al. [69] carried out a study on female AYA DTC survivors who underwent thyroidectomy and RAI and JOURNAL of MEDICINE and LIFE reported no negative long-term impacts on their QoL, self-esteem, or pregnancy outcomes.

Patient perceptions
The association between patients' perceptions and anxiety, depression, or QoL in TC has been reported in 16 studies [17, 34-36, 40, 43, 44, 46, 71-78]. Patients' worries over recurrence were linked to impaired QoL [35]. According to Henry et al. [71], common sources of fear for patients with TC included surgical complications, metastasis, and a perceived lack of support due to feeling overlooked by the healthcare system.
Randle et al. [72] reported that TC patients were aware of how TC is thought of as a "good cancer" by medical professionals, their peers, and internet websites, which resulted in their fears feeling invalidated. Smith et al. [40] reported that although younger TC survivors understood the concept of a "good cancer," this did not offset the negative aspects they experienced. The study identified the common theme of "biographical disruption," where survivors struggled with a loss of youthful immunity, uncertainties about the future, fears of recurrence, and feelings of being disregarded, vulnerable, and isolated.
Several studies have demonstrated that fear of recurrence and a negative outlook on life is linked to decreased quality of life (QoL) among individuals with TC [17,34,[73][74][75]. Chen et al. [46] reported that patients who overestimated their risk of cancer recurrence also worried more about death and reported a lower QoL. Hedman et al. [76] found that fear of recurrence and fear of exhausting effective treatment options in the future were related to increased anxiety levels. In addition, several studies [36,44,77] showed that perceived stress, or having more negative perceptions of cancer, was associated with lower QoL. Kurumety et al. [43] found that patient perceptions regarding neck appearance after surgery were also associated with changes in quality of life (QoL). The study showed that patients over 45 and those who had undergone surgery more than two years before reported better-perceived neck appearance and QoL than those with more recent surgery. However, after two years, the perceptions of TC patients regarding neck appearance had fully returned to the pre-operative baseline. These findings suggest that while cosmetic appearance may impact QoL, its effect may be lost in the long term.

Protective factors associated with anxiety, depression, and QoL in TC patients
The association between protective factors and anxiety, depression, or QoL in TC has been reported in 3 studies (Table 4) [79][80][81]. One prospective study [79] established that patients who received more dedicated time for information-giving were less anxious about the treatment and concluded that good communication between the patient and the medical team is associated with increased QoL. A randomized control trial by Wang et al. [80] assessed TC patients who received the psychological nursing intervention compared to TC patients who did not and reported that patients who received the nursing intervention had significantly lower levels of depression, anxiety, and mood disturbances compared to the control. Similarly, Wu et al. [81] reported that psychological nursing interventions resulted in greater improvements in QoL, depression, and anxiety compared to conventional nursing.

DISCUSSION
The current scoping review was conducted to investigate the effects of TC on anxiety, depression, and QoL of patients and to examine the various risk factors associated with lower QoL in TC patients. Overall, TC survivors were found to have a worse QoL compared to the general population [14, 16-18, 20-22, 24-29], patients with benign thyroid pathology, and even survivors of other cancer types with worse prognoses [30][31][32][33].
The factors associated with increased anxiety and depression and decreased QoL were grouped into socioeconomic factors, disease-specific factors, management factors, comorbidities, and patient perceptions ( Figure 2).
Most of the studies supported that a younger age at diagnosis as well as being female is generally associated with increased anxiety, depression, and a worse QoL [14,24,28,33,43]. Some studies reported that being married/having a partner was a protective factor for a higher QoL [15,35,45], and others supported it as a risk factor for poorer QoL [39,44]. In addition, there was significant evidence that higher education plays a favorable role in TC survivors' QoL and anxiety [15,33,34,44,46]. However, some studies found that higher levels of education were associated with lower QoL and more anxiety [24,47]. Studies also reported that financial difficulties were associated with a lower QoL and/or more distress in TC patients [15,24,26,35,[47][48][49][50].
Our study supported some protective factors associated with increased QoL, which include good communication between the patient and the healthcare team via adequate and accurate information-giving, which can decrease patients' anxiety levels and improve their QoL [79]. Psychological and behavioral interventions were also shown to improve QoL and reduce depression and anxiety [80,81].
The findings of our scoping review indicate that there are still several gaps in our understanding of the effects of TC on the QoL, anxiety, and depression of patients. To address these gaps, future research should focus on conducting more rigorous studies, such as randomized controlled trials, to thoroughly assess the risk factors identified in this review. Additionally, qualitative research could help provide further insights into how both risk factors and protective factors impact the patients' experience of TC. Once the risk and protective factors are appropriately assessed, the emphasis could shift towards a more interventional and holistic approach for managing TC patients and survivors. Healthcare professionals should be educated on the risk factors depression were respectively measured using the Quality of Life Core Questionnaire, Self-rating Anxiety Score, and Self-rating Depression Score.
China QoL and functional capacities of both groups improved after RAI treatment. At 1-year follow-up, patients in the psychological and behavioral intervention group had more improvement in QoL scores, anxiety, and depression compared to those in the conventional nursing group. • Psychological and behavioral nursing interventions: associated with greater improvement in QoL, anxiety, and depression outcomes than conventional nursing Table 4. Studies examining protective factors associated with lower anxiety and depression and higher QoL in thyroid cancer patients.
associated with lower QoL in TC survivors, and studies could be designed on interventions specifically targeted toward improving QoL. It is expected that these studies could involve the development of successful interventions that could be incorporated into the routine management of TC patients.

CONCLUSION
TC is often overlooked as a "good cancer", which is not only a misconception given its strong association with anxiety, depression, and poor QoL but also undermines the experiences of patients and survivors. Nevertheless, TC patients and survivors face numerous risk factors associated with higher levels of anxiety and depression and lower QoL. Furthermore, limited evidence supports good communication between the patient and the healthcare team, and psychological and behavioral interventions may protect the patients from anxiety, depression, and low QoL. Therefore, TC policy survivorship programs should involve the education of multi-professional healthcare teams on the various risk factors associated with the development of anxiety, depression, and low QoL in TC patients. A holistic and multi-level approach is necessary to address the various challenges associated with this "not so good cancer", which should aim to address TC patients' concerns and enhance their quality of life during the survivorship phase.

Protective factors
• Good communication between patient and healthcare team; • Psychological and behavioural interventions.

Disease specific factors
• Current staging and histology; • Current disease status; • Time since diagnosis and management.